Healthcare Provider Details

I. General information

NPI: 1104706837
Provider Name (Legal Business Name): MOBILE LYMPHEDEMA CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 PINE ALLEY ST
FORT WALTON BEACH FL
32547-1216
US

IV. Provider business mailing address

804 PINE ALLEY ST
FORT WALTON BEACH FL
32547-1216
US

V. Phone/Fax

Practice location:
  • Phone: 850-803-6683
  • Fax:
Mailing address:
  • Phone: 850-803-6683
  • Fax: 888-857-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA COLLEEN BOOTHE
Title or Position: CLINICIAN
Credential: MSOT, OTR/L, CLT
Phone: 850-803-6683